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CHOLEKA: 



FACTS AND CONCLUSIONS 



AS TO ITS 



NATURE, PREVENTION, AND TREATMENT. 



EY 



HENRY HARTSHORNE, A.M., M.D., 

MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; FELLOW OF THE COLLEGE 

OF PHYSICIANS OF PHILADELPHIA; PROFESSOR OF HYGIENE IN 

THE AUXILIARY FACULTY OF MEDICINE IN THE 

UNIVERSITY OF PENNSYLVANIA, ETC. 




PHILADELPHIA: 

J. B. LIPPINCOTT & CO. 

18 06. 



• 






rf 



Entered, according to the Act of Congress, in the year 1866, by 

HENRY HARTSHORNE, A.M., M.D., 

In the Clerk's Office of the District Court of the United States for the 
Eastern District of Pennsylvania. 






ON CHOLERA. 



Some experience with Cholera, in this city in 
1849, 1850, and 1854, and in the latter year at 
Columbia, Pa., and the perusal of most of what 
has been written upon the subject, have impressed 
me with opinions, some of which amount to strong 
convictions ; the truth of which — if they be true — 
is so important as to make it justifiable, if not a 
duty, to give them publication at the present time. 

Without claiming novelty for my views (some 
of which were published in a medical journal more 
than ten years ago*), my purpose is to endeavor 
to give the results of a careful analysis of the 
facts, and, if possible, an approach to a consistent 
theory, with direct practical applications. To this 
end, it will be best to attempt a brief digest of the 
subject, in a methodical form. 

Principal Synonyms. — Epidemic, Spasmodic, 
Malignant, Algid, Asiatic, Indian Cholera ; Cho- 
lera Asphyxia, Mort de Chien ; in India, Vishuchi 
(vomiting and purging) ; at Bagdad, Haouwa (tor- 
nado). 



* Philada. Med. Examiner, Aug. 1855; On Animal De- 
composition as the Chief Promotive Cause of Cholera, etc. 



(3) 



ON CHOLERA, 



DEFINITION. 



An acute systemic epidemic disorder (endemic 
in parts of India), not contagious, but produced 
under certain local circumstances by an unknown 
specific cause, which appears to be in rare in- 
stances and to a very limited degree portable; 
the symptoms being, in most instances, a premoni- 
tory, painless, and mostly watery diarrhoea of 
variable duration, followed by vomiting, also 
watery, and increased diarrhoea, with weakness, 
coldness, intense thirst, difficulty of breathing, 
loss of voice, cold breath, cramps, disappearance 
of pulse, suppression of the action of the kidneys, 
restlessness, and a blue or livid and shrunken 
aspect of the skin ; which symptoms may end in 
death in from ten minutes to forty -eight hours — 
in relief and rapid recovery within twelve hours 
or more — or, in a partial reaction and low fever 
{chiefly urasmic), the result of which is either 
death in a few days, or recovery in a week or 
two. 

APPEAKANCES APTEK DEATH. 

Rigidity occurs soon; sometimes in less than 
an hour ; generally within two hours. Startling 
movements of the corpse have been several times 
noticed ; as of a patient, dead with cholera, slowly 



APPEARANCES AFTER DEATH. 5 

lifting both hands over the chest and joining them ; 
opening the eyes and rolling them downward, etc. 
Increased heat of the body, cold during the attack, 
has been sometimes observed after death. Intern- 
ally, several of the great organs, the brain, spleen, 
and kidneys at least, are commonly gorged with 
blood. So are the right cavities of the heart; but 
the left side of the heart empty or with but little 
blood, and firmly contracted. The lungs are al- 
most bloodless. The liver varies in appearance ; 
but the gall-bladder is almost always full of bile. 
The urinary bladder is, constantly, greatly con- 
tracted. The- stomach and intestinal canal are 
congested, and swollen ; the late Prof. Horner ob- 
served the frequent throwing off of the " epithelial" 
lining of the canal ; Bohm, of Germany, confirmed 
this ; Drs. Parkes, Gull, and Lindsay assert it to be 
a post-mortem occurrence.* The intestinal glands 
are found considerably enlarged. The blood 
has been carefully examined by Drs. Garrod, 
Schmidt of Dorpat, and others, f Its water and 
salts transude into the alimentary canal, with 
some of the albumen and fibrin ; also the contents 
of the blood-cells transude into the serum. The 
blood drawn from a vein during life is (as I have 
seen it) dark, thick, and tarry, scarcely capable of 



* Edinburgh Med. and Surg. Journal, Jan. 1855. 
f Brit, and For. Medico-Chirurg. Rev., July, 1854. 



6 ON CHOLERA. 

flowing. Schmidt found the amount of oxygen in 
the blood-corpuscles less than half the normal pro- 
portion. The blood is acid sometimes in cholera ; 
the reverse of its natural reaction. 

The ganglia of the "sympathetic" system have 
been often examined, and are frequently changed 
in appearance; congested, softened, altered in 
color; but no special change has been shown to 
belong to them in cholera. 

DIAGNOSIS. 

Common cholera morbus alone {absurd name, 
hybrid of Latin and Greek; as absurd also is 
cholera, from the Greek for bile, a cognomen for a 
disease in which the excreta are remarkable for 
the absence of bile), when severe, resembles epi- 
demic cholera so much as to be easily mistaken 
for it. The collapsed stage of the one, preceding 
death, is almost identical in appearance with the 
collapse of the other. But cholera morbus is 
caused by some irritant of the stomach and bowels, 
and is clearly an affection of those organs, not a 
toxaemia or systemic disorder; it is sporadic, not 
epidemic ; in it the discharges are always bilious 
at first, and mostly so to the last ; collapse in any 
degree is rare, and death, under judicious treat- 
ment very uncommon. In all these things, it 
differs greatly from Asiatic cholera. 



HISTORY. 



HISTOEY* 



Putting aside some possible resemblance to this 
disease in descriptions of Aretus and one or two 
other ancient authors, probably the epidemic in 
France of 1545, " trousse-galant," came more near 
to it. The earliest distinct account of cholera was 
that given by Bontius, a Dutch physician of Ba- 
tavia, 1629. Willis (1684), Morton (1692), and 
others, described epidemic fluxes and " dysenteries" 
in England in such terms as strongly to remind us 
of cholera ; and so did Degner of Nymwegen, in 
the Netherlands (1T36), and Morgagni in Italy, in 
1733. Some British physicians (Greenhow, Ait- 
ken) now believe that cholera may have repeatedly 
visited England. It appears to me more probable, 
however, that this opinion is due to an overesti- 
mate of the resemblance between the autumnal 
cholera morbus of Great Britain (like our own) and 
the pestilential disease. 

Certainly cholera must have existed in India for 
an indefinite time. From 17 8 1-2 dates its extended 



* In this sketch I am chiefly indebted to Dr. A. Brig- 
ham's Treatise on Cholera, Dr. E. H. Greenhow's and 
Dr. Gavin Milroy's papers in the Brit, and For. Medico- 
Chirurg. Review (April, 1856, and October, 1865), and 
Boudin's Traite de Geographie et de Statistique Mddicales, 
tome ii. 



8 ON CHOLERA. 

prevalence, in a most destructive form ; at Cal- 
cutta, in Madras, on the Coromandel coast, and in 
Ceylon. 

In August, 1817, Jessore was the birth-place of 
the first great migratory epidemic. Shortly after, 
in Calcutta, 36,000 were attacked in three months. 
At many military stations, it was very severe. 
Roads were covered with dead and dying, unable 
to reach their homes. In November, the grand 
army of the Marquis of Hastings was devastated 
by it. Of 90,000 men, in twelve days 9000 had 
died. On marching the army across a river to dry 
and elevated ground, the commander was relieved 
of this otherwise invincible enemy. 

In 1818, the Birnian empire was invaded by 
cholera; and there and elsewhere in Asia, its 
ravages were fearful. In 1819, 150,000 died of it 
in the Presidency of Bombay. It also reached 
Mauritius, 20° S. latitude, three thousand miles 
from any place before visited by it. The Island 
of Bourbon was visited in 1820; as well as the 
Philippine Islands. In 1821, Borneo and Java 
were affected ; and a large Persian army was re- 
pulsed by it from before Bagdad, without a battle. 
In 1822 its limits were much narrowed, and its 
destructiveness abated. 

India almost escaped in 1823, but China was 
ravaged by it; and it extended northwestward, 



HISTORY. 



9 



in that year, to Orenbourg, on the Ural, near the 
borders of Europe and Asia. In 1826 it passed 
the great wall of China in its northward progress ; 
but almost left Western Asia. It reappeared in 
Persia in 1829. 

Orenbourg was revisited in that year, and the 
epidemic there lasted from August to near the 
end of February. This city had a population at 
that time of 11,000, of whom 6000 were soldiers. 
Those first affected had no communication what- 
ever with any infected place. 

1831 saw the cholera in the north of Europe, as 
far as Archangel, near the Arctic Ocean, more than 
64° N. latitude. It reached Warsaw in April, 
during an insurrection, and was very fatal. Hun- 
gary suffered from May to September; losing 
100,000 of its population. In June, St. Peters- 
burg, and in September, Moscow, were reached 
by the pestilence. Berlin had it also for three 
months and a half, beginning in August. Mecca 
was attacked during the visitation of throngs of 
pilgrims, in May; of 50,000, as many as 20,000 
are said to have perished. In this year, while 
Hungary was infected, the Austrian s surrounded 
Vienna by a double cordon militaire; but in vain. 
The disease began there in August and continued 
for three months. The southern provinces of 
Austria and the Khineland were exempt. Con- 



10 ON CHOLERA, 

stantinople was affected by it, but not with very 
great severity. The Turkish government, that 
year, maintained no quarantine. Cairo suffered 
dreadfully in 1830-31 ; and so did Smyrna. 

Attacking Hamburg on the 11th of October, 
1831, it was officially announced at Sunderland, 
England, October 26th. It had occurred in several 
cases in England months before. Three or four 
weeks later it appeared at Newcastle ; and in De- 
cember, at Haddington, a Scottish town on the 
Tyne. 

Edinburgh and Glasgow first had cholera in 
January, 1832; London in February ; Dublin and 
Paris in March. London then suffered but mod- 
erately ; Paris terribly — especially in April and 
May ; 20,000 deaths. 

On the 8th of June, it first invaded our conti- 
nent, at Quebec ; and within a week, at Montreal. 
In the same month it was in New York and 
Albany. Philadelphia had its first cases in July. 
Between the 1st of July and the 18th of August, 
New York had reported 5337 cases, with 2068 
deaths. That city lost 3513 in all.* From the 
27th of July to August 18th, Philadelphia had 
1610 cases, with 615 deaths. Boston and Balti- 
more were moderately affected in August. 

* Dr. A. Clark, Lect. on Cholera. In 1834, New York 
lost 971; in 1849, 5071*; in 1854, 2509. 



HISTORY. 



11 



Detroit, Buffalo, Elizabeth City in North Caro- 
lina, Wilmington and Newcastle, Delaware, Nor- 
folk and Portsmouth, Virginia, and New Orleans 
were the principal of more than fifty towns in the 
United States reached by cholera in 1832. It had 
entered twelve different States before September. 

Havana and Mexico were attacked in the spring 
and summer of 1833. The City of Mexico, not- 
withstanding its great elevation above the sea, 
did not escape. 

Portugal was also first visited in that year; 
Spain but slightly until 1834. Northern Italy 
was affected in the autumn of the same year. In 
1835, Alexandria and Malta; in 1836, Rome, 
Naples, Egypt, and Central America especially 
suffered. North Germany, South France, Rome, 
Naples, Sicily, Malta, Egypt, and Syria, in 183T. 
After that, cholera disappeared from Europe and 
America for nearly ten years. It still existed, in 
variable violence and extent, in India. 

In 1847, it ravaged a Russian army west of the 
Caucasus; and in September returned to Moscow. 
In 1848, Turkey, Russia, Austria, Prussia, Bel- 
gium, Holland, Great Britain, and Prance (though 
not Paris) were successively attacked. Then the 
cholera showed its power to traverse the sea with- 
out human aid or agency, by attacking two emi- 
grant ships, a thousand miles apart, one sixteen 
and the other twenty-seven days out from Havre, 



12 ON CHOLERA. 

when no cholera was prevailing at that port* 
The cholera-cloud itself also reached New Orleans 
about the same time, and progressed up the valley 
of the Mississippi. New York was not affected 
by the visit of the infected ship ; the disease not 
occurring again there until May, 1849. 

Paris was reached by it in February of that 
year, but suffered the worst in June. Lyons now 
had it for the first time. Tunis and Algiers were 
visited toward the end of the year. 

In January, 1849, after Memphis, St. Louis, 
Missouri, was attacked. Chicago, Buffalo, and 
other towns on the lakes, in May. New York 
and Philadelphia in the same month. Baltimore 
had this year only a local epidemic, in July, in 
the Almshouse ; the restriction of which to one 
side of the building was very remarkable. As in 
1832, the mortality in Philadelphia was much less 
for the population than in New York : 1022 deaths 
occurred in our city ; New York had a mortality 
450 per cent, greater, f Canada was reached this 
time from the westward. 

In 1848-9, the number of deaths from cholera in 
England and Wales was over fifty-four thousand 
(54,398); in 1832-3, nearly thirty-one thousand 

* Report on Cholera in the United States, by Dr. James 
Wynne; and Dr. Gavin Milroy, Brit, and For. Medico- 
Chirurg. Review, Oct. 1865, p. 444. 

f Dr. J. H. Griscom, Medical Record, March 15th, 1866, 
p. 35. 



HISTORY. 



13 



(30,924). In London,* probably owing to greater 
attention to sanitary means, the mortality was 
two-fifths less the second time than the first. Some 
parts of Southern Rhin eland were visited in 1849; 
especially the filthy City of Cologne. 

Cholera lingered in various places almost spo- 
radically, in Europe and America, from 1850 to 
1854. Canada and the far West (Indiana also 
had cases every year) suffered the most, in this 
way, on our continent. In the West, emigrants' 
camps and military stations seemed especially to 
furnish its required local conditions. 

In 1853, Persia had it severely ; also some parts 
of Northern, Central, and Southern Europe (Co- 
penhagen, Hamburg, Berlin, Piedmont, Lyons, 
Paris, and Southern Portugal). Before the end 
of the year it was again in New York, New 
Orleans, and the West Indies. Mexico had been 
visited in the spring, and through the summer. 

1854 was still more a cholera year in Europe 
and in this country. Scarcely any European state 
or kingdom was exempt. The French, English, 
and Russian troops suffered from it much in the 
Crimea. Greece, Italy, Germany, France, Spain, 
Portugal, in short, all Europe was traversed by it : 
150,000 died of it in France alone; in England 



* London had 13,098 deaths from cholera in 1849; in 
1854, about 10,000. 



14 



ON CHOLERA. 



and Wales about 20,000. Newfoundland, on 
our side of the ocean, was reached for the first 
time in 1854. This was the year of the epidemic 
at Columbia, Lancaster County, in this State ; so 
remarkable for the absence of some of the usual 
promotive conditions of cholera. Our great cities, 
however, did not suffer nearly so much as in 1849. 

In 1855, the disease was widely spread in Eu- 
rope, though not very malignant except near the 
seat of war, before Sebastopol. Egypt and Pales- 
tine had it also. In Switzerland, which had been 
slightly touched before, Basle, Geneva, Zurich, 
and other places now suffered by it. The next 
year, 1856, still did not witness its withdrawal 
from Europe. 

Since that period, until 1865, I have no means 
at hand for tracing the movements of epidemic 
cholera. Dr. Gavin Milroy says that the countries 
hitherto exempted have been as follows : Australia, 
New Zealand, and other islands in the Pacific ; the 
Cape of Good Hope and adjoining settlements; 
the coast of Africa from the Cape as far north- 
ward as the Gambia, and including the islands of 
St. Helena and Ascension ; the Azores, Bermuda, 
Iceland, Faroe islands, and also the Orkney and 
Shetland; the southern half of the. eastern coast 
of South America, from the Rio Plata inclusive, 
Cape Horn, and the whole of the western coast 
of that continent, from the Cape and along the 
shores of Chili and Peru to Panama. 



HISTORY. 



15 



In last year, every one was familiar with the 
accounts of cholera in Arabia and Egypt in the 
spring, at Constantinople in July,* and afterward 
in several parts of Europe, extending, though with 
but moderate violence, as far as England. While 
its vast migrations seem to be as capricious or in- 
calculable as the flight of locusts, two local causes 
contributed at least to its severity in Mecca and on 
the Nile. These were the crowds of religious 
pilgrims at the former place, in the spring, and, in 
Egypt, the insalubrious circumstances attending 
the operations at the new Suez Canal. In both, 
" crowd-poison" was intensified to the greatest de- 
gree; so that the pest-cause might well find there 
strength for the renewal of its flight onward to the 
northwest. In Paris, in 1865, 6383 deaths oc- 
curred during the late visitation. 

I take from Dr. Brigham's treatise (published in 
1832) the following table, of the deaths from 
cholera in 1832, and their proportion to popula- 
tion : 





Population. 


Deaths. 


Equal to 




Moscow, 


350,000 


4690 


1 in 74 


• 


Petersburg, 


360,000 


4757 


1 74 




Vienna, 


300,000 


11,896 


1 159 




Berlin, 


340,000 


1401 


1 242 




Hamburg, 


100,000 


446 


1 224 




London, 


1,500,000 


1223 


1 1228 





* The first case occurred in that city on the 28th of June. 



16 





ON CHOLERA. 




* 




Population. 


Deaths. 




Equal to 


Edinburgh, 


150,000 


72 


1 


in 2033 


Glasgow, 


180,000 


395 


1 


455 


Hungary, 


8,750,000 


188,000 


1 


46 


Paris, 


800,000 


20,000 


1 


40 


Montreal, 


25,000 


1250 


1 


20 


Quebec, 


22,000 


1790 


1 


12 


New York, 


200,000 


2000 


1 


100 


Albany, 


24,000 


311 


1 


77 



Supposing the population of Philadelphia to 
have been at that time 150,000, this, with a little 
over 600 deaths, would give a proportion for our 
city of 1 in 250 of the inhabitants. In 1849 the 
ratio was considerably less.* 

It is an important fact in the history of cholera, 
that before, during, and after the epidemic has 
visited a place, many cases, greatly exceeding in 
number those of typical cholera, occur, of diarrhoea, 
sometimes also with vomiting, not violent, yield- 
ing easily to treatment. To these the name of 
cholerine is often given, f 



* Moreau de Jonnes estimates the number attacked as, 
in France, 1 in 300 of the population ; Russia, 1 in 20 ; 
Austria, 1 in 30 ; Prussia, 1 in 100 ; Poland, 1 in 32 ; Bel- 
gium, 1 in 120; Great Britain and Ireland, 1 in 131; Hol- 
land, 1 in 144; Germany, 1 in 700. 

f The coincidence or anticipation of cholera by epidemic 
influenza and the potato blight, has been several times 
noticed. But there is, clearly, no uniformity in any such 
association. 



NATURE. 



IT 



NATTJEE OP CHOLEEA, 



Without discussing opinions at length, it may 
be asserted that cholera is not at all, like our ordin- 
ary cholera morbus, a disorder simply of the stom- 
ach and bowels. Being clearly an acute systemic 
affection, changes in the blood are proved to occur 
in it, and may well be believed to be primary; 
that is, that the morbid cause acts through the 
blood. But that is not all. 

Cullen placed cholera, in his nosology, in the 
class neuroses, order spasmi. Many medical ob- 
servers (Binaghi, Loder, Orton, Delpech, Lizars, 
Coste, Favell, C. W. Bell, Greenhow, G. Johnson, 
etc.) consider its principal effects to be referable 
to disturbed innervation, involving chiefly the 
ganglionic centres of organic life. Dr. Charles D. 
Meigs, years ago, graphically called the attack the 
"cholera squeeze." Yelpeau, of Paris, lately re- 
peats this, " le mal vous tortille." There, I think, 
is the pathology of cholera, in one word. As Dr. 
C. W. Bell says, it is not an adynamic, but a 
dynamic, or sthenic, collapse. 

The heart, its left side at least, is, after death, 
contracted. The pulmonary artery and its branches 
are narrowed, making the lungs pale and anaemic. 
The gall-bladder is full of bile, but the duct is 
spasmodically closed, and detains it there. The 



18 ON CHOLERA. 

urinary bladder is shrunken to half its size or less. 
The blood-vessels of the whole alimentary canal 
press rigidly upon their contained fluid, and force 
its serum out into the stomach and bowels ; whence 
it is, by spasmodic ejections, thrown out. The 
very skin is, by its involuntary muscular fibres, as 
well as by vascular constriction everywhere, drawn 
tightly and closely upon the body. The voluntary 
muscles suffer with cramps. All is cramp, cramp, 
within and without. The brain is almost in 
anaesthesia during the collapse — no delirium, but 
apathy — as from cerebral anaemia. The blood, so 
compressed, grows thick as tar — it scarcely flows, 
is not aerated, and cyanosis follows ; — it is detained 
in the capillary and venous networks of the in- 
terior organs, in which congestion is found after 
death. 

Cholera is, then, I say, a poison-spasm ; a gan- 
glionic tetanus. 

CAUSATION. 

Here we enter, unavoidably, the region of specu- 
lation. Not, however, without facts to give us 
hope and promise. By exclusion, we can first see 
what the cause of cholera is not. 

1. Is it heat, moisture, electricity, ozone, or any 
modification or combination of the pervading 
physical forces of nature? Surely not. Those 



CAUSATION. 



19 



forces are cosmic, not localized in their operation. 
Observation would hardly be needed to show that 
no state of physical conditions marks the presence 
of a cholera epidemic ; but observation has shown 
it. Sir Henry Holland* compared the atmospheric 
conditions of five different places in which cholera 
was prevailing ; there was no correspondence at 
all. Barton has found a high dew-point during 
cholera in New Orleans ; but it prevails often in 
India where the air is dry. Dr. Moffatt lately has 
asserted that the equatorial current of moist, ozo- 
niferous air is fatal to the prevalence of cholera. 
Berigny, in 1856, thought a deficiency of ozone to 
coincide with cholera ; but Berigny has, just now, 
asked and obtained the appointment of a learned 
commission of the French Academy, to ascertain 
definitely whether there is such a thing as ozone ! 
Dr. Hammond, in Kansas, found no ozonometric 
reaction during cholera; but Prof. Ellet, of New 
York, proved, in 1849, that there was no constant 
relation between the two.f Schultze, Yoltolini, 
and others assert the same conclusion. As to 
climate, the disease has prevailed from Archangel 
to the Isle of Bourbon, and from China to Mexico. 
No telluric causation, therefore, can suffice for it. 
Elevation has no fixed relation to its occurrence. 



* Medical Notes, Philadelphia ed., p. 349. 
f Hammond on Hygiene, pp. 164-165. 



20 



ON CHOLERA. 



In London, Dr. Fan* found the mortality to be 
directly in proportion to the lowness of site. But 
cholera has prevailed 9000 feet above the level of 
the sea, at Bogota, in 1849 ; ^000 feet, at Enimeneh 
in Persia, in 1853;* more than once in the City 
of Mexico, at an elevation of T990 feet; and in a 
citadel built upon an isolated rock ( Jaragurth, in 
Bengal), f 1000 feet above the plain. We must 
explain the influence of lowness of site, as Dr. 
Baly pointed out, merely as one of the circum- 
stances which modify the prevalence of cholera; 
not as accounting for it. 

Coming and going, then, across the earth, from 
time to time, its cause cannot be conditional 
merely. Nor, if it were so, could it happen that, 
among multitudes of persons, in the same spot, 
" one should be taken and the others left." 

2. If, then, not dynamic or cosmic, this cause, 
though occult, must be material. Nor could a 
mineral solid, or liquid, possibly so traverse the 
earth undetected per se. It must be, if inorganic, 
volatile, to cross the ocean alone. That it can do 
so, has been proved in a number of instances. 
Those of the emigrant ships, New York and 
Swanton, in 1848, from Havre, have been already 
alluded to. In 1854, I had direct cognizance of 



* Gavin Milroy, op. cit., p. 449. 
f Brigham, op. cit., p. 33. 



CAUSATION. 



21 



such occurrences, in the packet-ships Tonawanda 
and Tuscarora, Cope's line, between this city and 
Liverpool. The first was attacked when two 
weeks at sea, there being no cholera at Liverpool 
when she started. After a number of days' pre- 
valence, this vessel neared a large iceberg, which 
reduced the temperature of the air 30°. The day 
before the iceberg was met, the largest number of 
cases occurred ; after that, no new one at all. The 
epidemic was frozen out. In April, 1866, other 
instances occurred, to which allusion will be made 
hereafter. 

Since, then, I say, the cholera cause can travel 
far over sea, or land, it must be volatile, or ex- 
tremely mobile. Is it a gas? Chemists have not 
found such ; but that does not quite disprove it. 
But the diffusion of all gases through space, 
aided by the winds, prevents the local accumula- 
tion of gases everywhere, unless constantly eman- 
ating from a terrestrial source. Thus the mephitic 
poison of the celebrated deadly valley of Java, and 
the carbonic acid stratum of the Cave of Dogs 
in Italy, are accounted for. No poisonous gas, 
according to all physical experience, could pos- 
sibly maintain concentration enough to destroy 
human life, during weeks and months together, at 
one place, and then leave it to rest upon another 
— unless a source of emanation were as migra- 
tory. As no such mobile source is known, the 
gaseous hypothesis must explode of itself. 



22 ON CHOLERA. 

3. What possibilities, then, are left ? I have 
observed that, if inorganic, the " cause" in ques- 
tion must be a gas ; but it has been shown, just 
now, that no such gas can have existence ; there- 
fore the cause must be organic in nature. I see 
no escape from this dilemma, however wanting we 
are in physical demonstration of the conclusion it 
brings on. The source^ at least, of the cholera- 
cause must be organic. 

4. What organic sources are possible for it? 
Conceivable theories are — I. That it is a contagi- 
ous effluvium from the bodies of those sick with 
the disease. II. That it is generated by a pecu- 
liar chemical change in the excreta, either of the 
sick or the well. III. That it is a cryptogamous 
vegetation, a microphyte, requiring certain pecu- 
liar and only occasional conditions for its ex- 
istence. IY. That it is minutely animalcular in 
nature, existing, migrating, and propagating itself 
only where local circumstances permit. 

I. Is cholera contagious ? The word is vari- 
ously defined. I follow La Roche and others in 
regarding a disease as contagious, only, when its 
cause is a material produced by a morbid process 
in the bodies of the sick, and generating the same 
disease in those whom it reaches, either by con- 
tact or at a short distance through the air. In 
this sense it is proper to assert most emphatically 
that cholera has never been shown to be contagi- 



CAUSATION. 



23 



ous in a single instance ; while the always difficult 
negative proof is abundant. Every apparent case 
of contagion (and such are extremely rare) is 
susceptible of a different explanation. 

Against contagion we have, especially, the fol- 
lowing points : 

A. Cholera is often preceded in a place by a 
considerable increase in the amount of diarrhoea; 
showing the presence of a general atmospheric 
cause, the intensification or accumulation of which 
brings on the epidemic. 

B. It subsides in a locality, after days, weeks, 
or months, with no constant reference to the num- 
ber of persons susceptible to it, but obviously in 
relation to local sanitary conditions. 

G. It attacks, simultaneously, places as far apart 
as London and Newcastle; and often hundreds 
the same day in a large city. Thus seven thou- 
sand perished from it in Paris in eighteen days, in 
1832. In the Massachusetts State prison, four 
within an hour, and two hundred and five within 
forty-eight hours, were attacked. 

D. Cholera is sometimes limited to a part of a 
town (Oxford, England, according to Drs. Baly 
and Gull) or even a part of a house ; as at Balti- 
more in the Almshouse, in 1849. Dr. Buckler 
then reported its existence, when there was no 
cholera elsewhere in the city, in one-half of the 
Almshouse building, in which seventeen fatal cases 



24 



ON CHOLERA. 



occurred ; none whatever in the other half, simi- 
larly occupied. The difference was, that under 
the walls of the affected side of the house was " a 
large and foul overflowing cess-pool, whose con- 
tents mingled with the washings of the dead- 
house, etc." In several instances, also, it has been 
confined to a part of a ship.* 

E. An army or other encampment may be 
affected terribly while in one locality (as with the 
Marquis of Hastings in India, mentioned before), 
and then, by a short march, escape from it alto- 
gether. Such occurrences are frequent and fa- 
miliar in India. (See S. Clark, Hygiene of the 
Army in India.) 

F. In Hindostan, where cholera is annually 
present, the facts are of such a nature that the 
idea of contagion is scarcely entertained by any 
medical men or others. Dr. James Johnson 
wrote, many years ago, that "in India, the con- 
tagiousness of cholera is denied by ninety-nine out 
of every hundred medical men." And in a work 
published in 1864, on the Hygiene of the Army 
in India (Stewart Clark, M.R.C.S., Inspector- 
General of Prisons, etc.), I find statements corro- 
borative of this. For example, the following : 

"After the Hurdwar and other large fairs in 
India, cholera almost always appears in the vil- 



* E.g. steamers England and Virginia, April, 1866, 



etc. 



CAUSATION. 



25 



lages on the lines of roads leading from them ; but 
the cases are generally confined to people who 
have been at these fairs. For instance, at Deyrah 
Doon, about forty miles from Hurdwar, there are 
often two annual visitations of cholera: viz., one 
in April or May, confined to individuals returning 
from the Hurdwar fair ; and one later in the sea- 
son, of the usual epidemic type, among the gene- 
ral inhabitants of the town."* 

In the words of Dr. A. Flint, f " compare its 
course as an epidemic, in this respect, with typhus, 
small-pox, or scarlet fever !" 

G. Nurses and others brought into contact with 
cholera patients, even in hospitals, are not more 
liable than others to the disease. An official re- 
port to the French government stated that in 1831 ; 
of over two thousand persons employed in nursing 
in hospices or hospitals, during an epidemic of 
cholera (which produced in all eighteen thousand 
deaths), only one hundred and sixty-four were 
attacked. At St. Petersburg, 1 nurse in 58 had 
the cholera ; in Moscow, of 253 persons connected 
with x>ne hospital, 4 only were affected by it. In 
the latter city, also,J 587 patients affected with 
cholera were admitted into a hospital with 860 
patients, laboring under other diseases, yet not a 



* Op. cit., p. 13, note. f Practice of Medicine, p. 425. 
% Brigham, op. cit., p. §24. 



26 



ON CHOLERA. 



single one of the latter was attacked by cholera. 
Dr. Alison (himself half a contagionist) recorded 
the fact* that, in Edinburgh, in 1832 and in 1 848-9, 
the dissecting-rooms were supplied almost exclu- 
sively by cholera subjects; and in neither year 
was there a single case of the disease among the 
numerous students attending those rooms. Post- 
mortem examinations have been made freely, by 
physicians everywhere, during cholera, without 
any evidence of danger therefrom. 

H. No effort to produce cholera by direct con- 
tact or otherwise, experimentally, has ever suc- 
ceeded. Dr. Foy and ten others, at Warsaw, f 
inoculated themselves with the blood of cholera 
patients, tasted their dejections, and inhaled their 
breaths, without receiving the disease. So did the 
surgeons and medical students at Moscow and 
Dantzic in 1832; and similar experiments with 
like results and conclusions were tried by Lizars, 
Coste, Schmidt, Meyer, Marshall, and others. A 
late article in the Richmond Medical Journal, by 
Dr. Houston, mentions that a man in Wheeling, 
during a cholera epidemic, lay all night in the 
clothes of another who had just died of the dis- 
ease ; but was unhurt by it. 



* Brit, and For. Medico-Chirurg. Review, Jan. 1854, 
p. 22. 

f Gazette M^dicale, 1831, 



CAUSATION. 



21 



Dr. Lauer Lindsay* made elaborate experi- 
mentation with dogs; and thought he had suc- 
ceeded in giving them cholera. But it does not 
appear so to me, in reading his account. The 
dogs were exposed in no case less than seven days 
to the combined effects of confinement, swallowing 
and breathing the matters of evacuation and per- 
spiration of cholera patients. Then the symptoms 
ought not at all to be regarded as specific, as the 
discharges were "decidedly biliary, green, and 
greenish feculent matter," and " emitting an intol- 
erable stench." Dog No. 1 is also stated to have 
become somewhat lively and greatly better, after 
having eaten a quantity of the flesh, fat, and blood 
of dog No 2, which died on the previous day. 
The expression of Mr. Marshall, another investi- 
gator, is clearly correct — that this evidence is still 
"short of proof" of any contagion belonging to 
cholera. 

I cannot but anticipate that a similar conclusion 
would follow a scrutiny of the experiments of like 
character more recently performed by Thiersch in 
Munich, and Robin at Paris, f They have made 
dogs sick by injecting the excreta of cholera pa- 
tients into the trachea and veins. No wonder! 



* Edinburgh Medical and Surgical Journal, April and 
October, 1854. 

f London Lancet, Jan. 13th, 1866. 



28 ON CHOLERA. 

But, against all this we have the familiar fact that 
dogs do not get the cholera at all by exposure to 
the companionship of patients, nor by presence 
during its epidemic prevalence. Every experi- 
ment of the kind is simply toxicologieal, not clini- 
cal or a propos in any sense. 

The influence of drinking water, the occasional 
occurrence of new cases in hospitals to which 
cholera patients are admitted,* and all other seem- 
ing instances of contagious transmission, are, as 
will be shown hereafter, clearly susceptible of a 
different explanation, which embraces all the 
facts. 

I. Cholera does not follow regularly, nor de- 
pend for its migrations upon, human intercourse. 
Instances proving this abound in the whole his- 
tory of it ; a few must suffice us here. 

Whatever the amount of travel, cholera moves 
with extreme slownessf against the wind. This 
is especially observable in India ; where, as Orton 
has recorded, it takes sometimes three months to 
pass over the distance of a ten days' voyage, not- 
withstanding constant communication. 

When the epidemic first reached England, in 
1831, after having been in Berlin and Hamburg, 
it appeared in Sunderland October 26th. It did 

* Brit. Med Journal, Dec. 9th, 1865. 

I Parkes; vide Aitken's Practice of Med., vol. i. p. 659. 



CAUSATION. 



29 



not reach London until February, 1832 ; notwith- 
standing constant communication between that 
city and the infected district.* 

One of the Western Islands, beyond the coast 
of Scotland, on the other hand, was attacked by 
the disease, although the intercourse between it 
and the main land was so rare, that the clergyman 
of the island continued to pray every week for 
King William the Fourth, for eighteen months 
after Queen Victoria had ascended the throne, f 

In 1832 and 1848, the town of Annan, nearly 
equidistant from Carlisle and Dumfries, and right 
upon the main line of traffic between those towns, 
escaped cholera altogether, while it prevailed both 
at Dumfries and Caiiisle.J 

I repeat, that these are only instances of a large 
class of facts, which show a capriciousness in the 
career of cholera epidemics, altogether adverse to 
the supposition that it is either contagious or in 
any way dependent for transmission upon human 
intercourse. 

But the advocates of the view just now most 
prevalent, urge that on all occasions cholera has 
crossed the ocean only in ships. Each by each of 



* G. Milroy, Brit, and For. Medico-Chirurg. Review, 
Oct. 1865, p. 438. 

j- Aitken, op. cit., p. 650. 

% Edinburgh Monthly Journal of Med. Sci., April, 1854. 



30 



ON CHOLERA. 



the asserted instances of this has been or could be 
met and shown to be quite unproven. A single 
case of such disproval would establish for us the 
important proposition, that cholera certainly does 
not depend for its migrations upon human agen- 
cies or contingencies. 

What do we say of the New York and Swanton, 
vessels, in 1848? They have been already alluded 
to on a previous page. I say, first, that there 
was no cholera at Havre when they started, nor 
for some time before ; Dr. James Wynne* and 
Dr. Gavin Milroyf being my authorities for the 
statement. 

Secondly, I regard it as a decisive fact, that in 
all the accounts of the voyage of these vessels 
referred to, one is said to have been sixteen and 
the other twenty -seven days out at sea before any 
cholera occurred on board. 

Now what, according to the strictest contagion- 
ists, as well as those who believe in the theory 
of excretory fermentation (Pettenkofer), is the 
time of incubation of the cholera poison ? Budd,J 
Niemeyer, and Greifswald make it from six hours 
to three days; Kierulf,§ of Bergen, from one to 



* Report on Cholera in the United States, 
f Brit, and For. Medico-Chirurg. Review, Oct. 1865. 
J Association Journal, 1854 ; Memoranda on Asiatic 
Cholera, 1865. 

§ Aitken, Practice of Medicine, vol. ii. p. 657. 



CAUSATION. 



31 



four days; Rilliet, Madin, Weissbrod, Hielman, 
and others, twelve hours to eight days. 

How absurd, therefore, to endeavor to construe 
the case of the Swanton as one in which the 
cholera was transported from Havre to New 
Orleans by that ship ! The arrival of the New 
York at the port of that name was not followed 
by the infection of that city. I would say, that 
the arrival of the epidemic at New Orleans simply 
coincided, pretty nearly, with that of the Swanton; 
which had been overtaken by it on its way. While 
these pages are being written (April, 1866) two 
analogous cases are attracting attention ; those of 
the steamers England and Virginia, from Liver- 
pool; attacked by cholera when five and eight 
days out.* 

J. But something must be said of the authenti- 
cated instances where transportation by persons 
seems to have occurred. With a good deal of re- 
search, I have been able to collect together only 
the following, as allowable in evidence. 

Certain cases mentioned by Dr. Jameson, in the 
Bengal Report, in 1824. 

Eight persons taking cholera at Toulon, shortly 



* Some conjecture that German emigrants must have 
brought the disease to the England and Virginia; but, if 
so, why did they not likewise infect Liverpool ? 



32 ON CHOLERA. 

after the arrival there of the frigate Melpomene f 
from Lisbon, with cholera on board, in 1833.* No 
other cholera cases occurred at Toulon for two 
years. 

A woman attacked at Edinburgh, in 1832, when 
no cholera prevailed there, after nursing her son, 
who got the disease at Musselburg and came home 
sick with it.f 

Some instances mentioned by Dr. Simpson 
(Edin. Med. and Surg. Journal, April, 1838, and 
Edin. Monthly Med. Journal, 1849), quoted with 
only partial details by Dr. Alison (Brit, and For. 
Medico-Chirurg. Review, Jan. 1854). 

Three women took cholera after washing the 
clothes of some sailors who had died of cholera, 
at Banff, Moray Firth, Scotland, 1832.J 

Two men died of cholera, in 1849, at Campbell- 
town, Scotland, after the arrival of a woman from 
Glasgow, with some blankets which had been used 
by her sister-in-law who died of cholera. The 
disease then existed nowhere else within fifty 
miles (Dr. Robertson, Edin. Monthly Journal, 
August, 1849). 

Several instances are given by Dr. Berg, in his 



* London Medical Times, N. S., vol. iii. p. 515. 
f Ten days afterward cholera became epidemic in Edin- 
burgh. 

t Alison, loc. citafc. 



CAUSATION. 



33 



Treatise on the Cholera in Sweden, in 1850; of 
which I have not details. 

One case is narrated by Dr. S. H. Dickson, in 
Charleston, 1832 (Am. Journal of Med. Sciences, 
vol. xiii. p. 309). 

The outbreak of cholera at Arbroath, in Scot- 
land, in 1853, described by Dr. T. Traill (Aitken, 
op. citat , p. 656). Some instances in the Nor- 
wegian Reports of 1850-53. Others in the Report 
of the College of Physicians of London, 1854. A 
few cited from a Bengal Report, 1853, by Dr. 
Aitken.* 

A few cases mentioned by Boudin in his " Traite 
de Geographie et de Statistique Medicales" (tome 
ii. p. 37 4), viz.: 

Three- persons in the commune of Masles, in 
France, affected, in 1849, subsequently to the 
arrival of a person who visited Paris while cholera 
was prevailing there, returned to Masles, became 
ill, and died of cholera. 

One person, in the same year, in the commune 
of Conde, attacked after handling the clothes of a 
woman who had died of cholera ; there being no 
other cases at Conde at the time. 

Three individuals, in the same year, affected at 
Aubees, after the arrival there of a person from 



* Practice, p. 656. 

2 



34 ON CHOLERA. 

Courville, where cholera prevailed, that .person 
becoming ill and dying of cholera after his arrival. 

According to M. Bucquoy,* two wet-nurses, 
going from Paris to Peronne, and falling ill there 
with cholera (1865), communicated the disease to 
eight other persons ; some of whom died. 

In Dr. Burrall's recent work on Cholera, received 
since the above was written, several other exam- 
ples of an analogous kind are given. 

All of these, together, would count, I suppose, 
since 181?, possibly fifty or a hundred individuals, 
who might be acknowledged to have taken cho- 
lera, in immediate sequence upon exposure to con- 
tact with the persons or clothing of cholera pa- 
tients, in localities not at the time under the epi- 
demic influence. 

Granted, then, that such was the case. They 
are, clearly, exceptional instances. If cholera was 
in any proper sense contagious, could the instan- 
tise crucis possibly be so few and hard to find or 
prove ? No ! But how do we account for these ? 
On the principle of fomites; of occasional, very 
rare, carrying of the cause of cholera, the " germs" 
of it, in clothing, merchandise, or by the person of 
a human being ; as one might carry skippers on a 



* Discussions of Parisian Hospital Med. Society ; Phila- 
delphia Med. News and Library, Feb. 1866, p. 22. 



CAUSATION. 



35 



piece of cheese in his pocket, or a paper of flower- 
seeds in his carpet-bag. 

Practically, what is the difference between this 
and contagion ? Much, indeed ! When the cause 
of the disease is a somatic {bodily) contagion, no 
prevention of it is available, except the total and 
remote avoidance of those persons who have it, 
and of things which have been in contact with 
them. When the cause is an eatfra-soniatic infec- 
tion, depending, for its production, multiplication, 
and transportation, on local and atmospheric con- 
ditions, not personal — then those conditions may 
be met preventively; and the very rare carry- 
ing power of fomites may be reduced to nullity, 
by sanitary precautions. Against contagion, we 
would have only quarantine ; a most "lame and 
impotent " defence. Against infection, we have 
the amply sufficient measures of sanitary police 
and management. 

Contagion, as a theory, would explain only a 
minority of the facts concerning cholera, and is 
not required to explain them. Infection will ex- 
plain all. 

Let me here state briefly the main facts in refer- 
ence to the three vessels which have reached our 
shores within a few months, having cholera on 
board. 

The Atalanta arrived off New York on the 2d 
of November last, with emigrants, from Havre. 



36 



ON CHOLERA. 



In the steerage there were a number of cases of 
cholera during the voyage; none at all in the 
cabin. 

The steamer England reached Halifax April 
8th (the present month) from Liverpool, with 
1202 passengers, chiefly emigrants, Irish and Ger- 
man. When five days out, she was attacked with 
cholera. The disease did not then exist, and has 
not since (as shown by a number of arrivals from 
that port later) existed at Liverpool. It was, on 
the voyage and at the quarantine, confined entirely 
to the steerage.* 

The Virginia arrived, also from Liverpool, April 
18th, at New York quarantine station. She had 
1043 passengers, 14 saloon and 1029 steerage, most 
of the latter being German and Dutch. Leaving 
Liverpool on the 4th, on the 12th cholera broke 
out among the steerage passengers, in the " orlop," 
below the deck and beneath the water line : 37 
died during the voyage. After reaching quaran- 
tine, being detained there, the disease increased, 
but still was exclusively confined to the steerage 
passengers. 

Now, how did these vessels get the cholera ? 



* Eight passengers escaped from the England, and one 
died of cholera at Halifax ; without any other cases fol- 
lowing there. Dr. Slayter, of Halifax, went on board of 
the vessel, took the disease, and died of it. 



CAUSATION. 31 

Not at Liverpool, for there was none there. Did 
German emigrants bring it on board ? If they 
could have, why, as they stopped at Liverpool, 
did they not infest that city also ? But yester- 
day (April 30th), a steamer arrived direct from 
Hamburg, with no tidings at all of cholera in Ger- 
many. Dr. E. B. Dalton, Sanitary Superintendent 
of New York, and Dr. Elisha Harris, a distin- 
guished sanitarian, went officially on board the 
Virginia, and carefully questioned v the passengers 
in regard to their original starting-places. They 
had none of them knowledge of any epidemic in 
any place they came from or through. The near- 
est possible approach to anything whatever of the 
kind was said to be that, "during the past ivinter, 
the disease had appeared in certain towns in Sax- 
ony, near which some of them had resided !" 

Determined, indeed, must any one be to insist 
upon the communication theory, who will account, 
by a vicinity dating back to "last winter," for an 
epidemic commencing out at sea, in April, which, 
yet, in neither of three ships successively so af- 
fected (including the Atalanta of November), can 
be or has been communicated from the steerage to 
the cabin of the same vessel ! So palpable was 
the contrast of safety and of infection between the 
saloon — spacious, clean, and well aired — and the 
steerage — crowded, close, and unwholesome — that 
the cabin passengers on one of those vessels pre- 



38 



ON CHOLERA. 



ferred to remain upon it, in their apartments, to 
being removed elsewhere, in the immediate and in- 
salubrious company of the emigrants among whom 
the disease had proved so destructive. 

These cases appear to me extremely important, 
as explicable, clearly and consistently, only upon 
the view that the cholera-cause has the power of 
migration across the sea ; a crowded vessel, like a 
filthy city on land, affording the local conditions 
for its manifestation, propagation, and extension. 

Wishing to give fall legitimate effect to all that 
can be asserted of a different tenor from what I 
maintain, I quote the following from Dr. Harris, 
in a recent report:* 

"In studying the history of fourteen epidemics 
of cholera that have occurred within the walls of 
our New York quarantine establishment, the 
writer has seen abundant evidence of the infec- 
tious agency of the sick and their 'rice-water 7 
evacuations. 

" Concerning these repeated outbreaks of chol- 
era at quarantine, it should be stated, that while 
they proved how fatally infectious the cholera poi- 
son may become in the midst of crowded hospi- 
tals and public institutions, they have utterly failed 



* Report on Epidemic Cholera by the Council of Hy- 
giene and Public Health of the Citizens' Association of 
New York. November, 1866. 



CAUSATION. 



39 



to prove that from the same exclusive cause — viz., 
the contagion of the cholera evacuations — a world- 
wide epidemic could be caused. These outbreaks 
did prove, however, that the stools and besmeared 
clothing of the sick with cholera can, under cer- 
tain circumstances, propagate the disease ; while, 
on the other hand, a series of events at quaran- 
tine and in the city demonstrated, that, for the 
production of a wide-spread epidemic, other im- 
portant causes than the presence of the rice-water 
stools and vomitings must be present. " 

II. Let us now examine, briefly, the theories 
which connect the propagation of cholera exclu- 
sively with the discharges of those who have the 
disease. They are, that of the late Dr. Snow, of 
England, and those of Pettenkofer and Thiersch, 
of Munich. 

Snow's theory was, that a poison is generated 
by the morbid process of the cholera attack ; which 
poison passes from the bowels of the patient ; that 
this poison is conveyed by the water which ab- 
sorbs it from the tainted atmosphere about him ; 
and thus, through " continuous molecular change," 
it taints destructively the systems of those who 
drink such water, or the water of streams polluted 
by sewage or drainage into which cholera excre- 
ments pass. 

It has already, I consider, been shown — 1st, that 
there are facts which this theory will not account 



40 



ON CHOLERA. 



for; and, 2dly, that all the facts (many as they 
are) proving the important influence of drinking 
water over the mortality of cholera, can be ex- 
plained as well upon another, wider view. 

Pettenkofer's theory is much like Snow's ; but 
he supposes the poison not to pass as such from 
the bowels of the patient ; but that it is produced 
by a sort of post-excretory fermentation, which re- 
quires several days of time, and is effected in the 
water beneath the surface of the ground. He 
makes a very large estimate of the importance of 
the soil and substrata of a place in determining 
its liability to cholera. He denies that it can ever 
prevail over rock. 

On this I would remark — 1st, that it has pre- 
vailed upon rocky sites ;* 2dly, that this theory 
cannot, any more than Dr. Snow's, explain all the 
facts ; 3dly, that a theory which will account for 
all other facts, will also explain those on which he 
relies. 

Dr. Parkes and others seem ready to make use 
of a recent modification of Pettenkofer's views, 
which is certainly convenient and ingenious. This 
is, the hypothesis that the "germs" of cholera 
poison, once produced, are not destroyed for some 



* See Brit, and For. Medico-Chir. Review, Jan. 1857, p. 
66; also, Brigham on Cholera, p. 33; Drasche, Die Epi- 
demische Cholera, Vienna, 1860; Kiehl, Ueber den Ur- 
sprung und die Veihutung der Senciien, etc., Berlin, 1865. 



CAUSATION. 



41 



time by desiccation ; that the tainted faecal mat- 
ters, though formed in water, may become dry 
enough to be carried, as dust, through the air. 

This is, I believe, at the present moment, the 
theory which has the greatest number of influen- 
tial advocates in England ; and some elsewhere. 

I ask, can it be imagined that such cholera dust 
(if not endowed with the vitality of microphytic 
sporules or animalcular ova) could multiply as the 
cholera cause must, or could be swept over the 
ocean far enough to reach a vessel two weeks and 
more from the shore it had left ? 

The parenthetical words of this last sentence 
imply the direction in which my reasonings (and, 
I hope, those of my reader also) are, by exclusion, 
impelled. 

III. An organic nature, that of a living organ- 
ism, is thus suggested as most probably belonging 
to this undiscovered cause. The combination of 
persistent identity, with extensive mobility, can, 
I think, be no otherwise explained. I regard this 
as not at all a vague conjecture, the mere resort 
of ignorance ; but as a logically obtained scientific 
hypothesis ; needing but little, if anything, to make 
it a theory worthy of universal adoption and appli- 
cation. It has been, in such a sense, considered 
seriously by such careful reasoners as Sir H. Hol- 
land, Prof. Alison, and Prof. Max Pettenkofer. 

I repeat the question — can it be imagined that 



42 ON CHOLERA. 

an excrementitious "dust," not organic or vitalized 
at all, should multiply itself so as to account for 
the world-wide spread of cholera ? 

If it could, observe then the other horn of the 
delemma ; how could it ever cease doing so ; how 
could cholera ever stop, until the human race was 
destroyed ? At all events, how could it disappear 
as it does, after visitation, from Europe and Amer- 
ica, for long terms of years ? 

Variability in reproduction, under complex and 
partly unrecognized causes, is a characteristic of 
animal and vegetable life. This would account 
for such facts, and this alone. 

The organic theory has been asserted in two 
forms:* the vegetative or microphytic, and the 

* Vide Holland's Med. Notes and Reflections; Essay on 
the Hypothesis of Insect Life as a Cause of Disease. I 
cite from this work the following curious facts : 

" The Hessian fly, on its first appearance in America, 
afforded a singular example of slow progressiva movement. 
First observed in Long Island, in 1776, it proceeded into 
the interior, at the rate of ten or fifteen miles in the year, 
destroying all the wheat in its progress. The spread of 
the Blatta orientalis in northern Europe is another fact of 
a similar kind." 

"In October, 1836, a vast swarm of minute aphides 
passed over a wide district in Cheshire, Derbyshire, and 
other counties. The air was so thickly filled with them, 
that the clothes and faces of persons walking out of doors 
were completely covered. From observations taken, the 



CAUSATION. 



43 



animalcular. The first is not set aside by any 
positive facts ; but it does not explain any more 
than the second ; while the remarkable mobility 
or migratory power of the mysterious agent in 
question points rather to the animalcular theory. 

IY. To this, then, we are brought at last ; with 
only one other alternative, as, not a substitute, but 
an amendment for it. I mean the view advanced 
recently by two members of the Philadelphia 
Academy of Natural Sciences, the late Dr. Wilson 
and J. Cassin ;* that reason exists for distinguish- 
ing a third kingdom of nature, besides animals 
and plants ; for which they propose the name of 
Primolia. If such organisms as sponges, many 
infusoria, volvocineae, diatoms, and desmidise, have 
attributes neither animal nor vegetable, and yet 
clearly organic, it is evident that our previous 
classifications of natural forms are incomplete. 



superficial extent of the mass must have been at least 
twelve miles in one direction by five miles in another ; but 
detached notices from other places make it certain that the 
continuous swarm was much more widely spread. No 
proof was obtained as to its rate of movement ; but Man- 
chester was infested for two or three successive days. 
Wherever generated, there is cause to suppose that the 
swarm was in transit from one place to another, and pos- 
sibly brought nearer to the earth by some peculiar state 
of the atmosphere." 
* Proceedings of Acad. Nat. Sciences of Philadelphia. 



44 ON CHOLERA. 

So are our observations. With each increase 
in their means and facilities, come new discoveries. 
No limit to microscopic, any more than to tele- 
scopic possibilities. Because we have not found 
any peculiar cholera animalcules, or primalia, it 
does not at all follow that they have no existence. 

The chief haunt and residence of cholera being 
in warm or hot climates, with luxuriance of or- 
ganic development, this is strongly in favor of the 
hypothesis. So is its general prevalence in tem- 
perate regions during the warmer part of the 
year.* 

Against it, we have two facts especially ; as fol- 
lows: 

Firstly, cholera has, on a few occasions, prevailed 
in cool or cold latitudes ; as in winter in the north 
of England, and the north of Russia. As to this, 
it has been recorded that the winter of 1831-32, 
when it existed in the north of England, was, as 
shown by Mr. Losh's Meteorological Journal,f 
exceptionally mild. In Russia, also, the summer 
of 1830 was oppressively warm, and the disease 
began at Moscow in September. In the cities of 
northern Russia, moreover, the domestic habits of 

* September has had, altogether, the greatest number of 
deaths. Vide Brigham on Cholera; G. Milroy, loc. cit., 
etc. 

f Brit, and For. Medico- Chirurg. Review, April, 1856, 
p. 304. 



CAUSATION. 45 

the population, in heating their houses, maintain a 
sort of green-house, or internal warm climate, 
throughout the winter. Thus, any " germs" trans- 
ported thither in the summer or autumn, if other 
favoring circumstances were present (as they 
are), might well be kept alive. Moreover, as Dr. 
Routh has shown, the poorer Russians throw out 
everything around their houses ; and then melt 
the snow for their drinking water. 

It may be incidentally mentioned, that the me- 
teorological conditions most frequently coinciding 
with the outbreak and continuance of cholera, are, 
those of moderately high temperature, and stag- 
nation, or deficiency of atmospheric change or 
movement.* 

Secondly y it has been very plausibly assertedf 
that no parasite, invading or residing in the human 
body, ever causes violent or destructive acute 
disease; but only slow local disorders. Before 
trichiniasis attracted the attention now drawn to 
it, this statement had more weight than now. Of 
animal or vegetable parasites there had been, per- 
haps, before, only one record of any that had en- 
dangered life by residence in or upon the body ; 
that of the mycetoma, or disease produced by a 

* Glaisher, Meterology of London during cholera, etc.; 
T. H. Greenhow, loc. cit. 
f J. Simon, Lectures on General Pathology. 



46 ON CHOLERA. 

peculiar fungous vegetation attaching itself to the 
limbs, in India, as described by Dr. Carter, of 
Bombay. And the effects of this were slow; no 
acute systemic malady was produced. But the 
lives destroyed by trichinae lately in some of the 
German towns afford instances of importance. It 
is especially notable that these last parasites seem 
to act by numbers; a few may be detected in the 
flesh of animals or men, without serious injury to 
either ; it is by multitude that they disturb seri- 
ously or even kill. 

However, the "organic" theory does not require 
parasitic action to make it possible. Life is only 
predicated as an attribute of the cholera-cause in 
accounting for its variable multiplication and mi- 
grations. Its mode of action upon the human 
body is a separate question. It is most probable 
that it is not by parasitic residence ; but by enter- 
ing the system as an organic poisonous material. 
For the action of such material, of animal origin, 
abundance of analogy exists ; as in the toxic effects 
of cantharides, of in sect- stings, venom of serpents, 
and of rabid animals ; of dissecting wounds, and 
spoiled meat or sausage used as food. 

My theory, then, is as follows : That the cause 
of cholera is a (yet undiscovered) protozoon, or 
primal organism, of extreme individual minute- 
ness ; which, on entering the human body, affects 
it as an organic poison. That the varying quan- 



CAUSATION. 47 

tity or number of these organisms may in different 
cases account (along with individual predisposi- 
tions and exposures) for the unequal violence of dif- 
ferent epidemics ; as in the case of trichiniasis. Cho- 
leraic diarrhoea or cholerine, so frequent before as 
well as during and after the prevalence of cholera, 
may in some instances at least be explained by the 
action upon the alimentary canal only, of a mini- 
mum quantity of the cause. The dreadful fatality 
of some Indian seasons, is on the same view re- 
ferred to an extreme accumulation of it. 

A most important part of the theory is, further, 
that which concerns promotive causation. What 
conditions favor and maintain in life, multiplica- 
tion and migration, this ens primalis f 

All the facts answer, as I believe, that animal 
matter in a state of rapid and foul decomposition, 
putrefaction, along with moderately high (not the 
highest) temperature, and ordinary moisture, will 
afford those conditions ; and that nothing else is 
required to explain the whole history of the pro- 
pagation and extension of cholera. Nothing, I 
mean, but the admission of the existence of the 
"protozoon," which in ova or in maturity, or 
both, may fly "on the wings of the wind;" or be 
conveyed to less distances by water; and, with 
these the above-named conditions of its vital main- 
tenance, as its food and " habitation. '? 

It is, in my mind, obvious that this theory will 



48 * ON CHOLERA. 

explain all the facts. I believe, also, that some 
well-known facts can be explained by it alone. 

As to the general facts, I can scarcely do better 
than repeat, with some extension, words written 
eleven years ago, and referred to at the beginning 
of this essay.* 

The Gangetic delta being the great focus or 
centre of cholera, certain traits in the usages and 
circumstances of that locality and its population 
have a direct bearing upon the subject. Among 
these may be named the peculiarity of the inhab- 
itants in disposing of the dead. Most of them 
either burn the bodies, and this very imperfectly, 
or throw them into the Ganges or its tributary 
streams; that river being held to be sacred ■ — a 
gateway to heaven. In the Hooghly river, Stewart 
Clark says,f he has seen "upwards of fifty dead 
human bodies, besides numbers of carcasses of 
lower animals, floating within sight at one time." 
At Allahabad, at the junction of the Ganges and 
the Jumna, many persons drown themselves as 
devotees, and others are often drowned by the 
pressure of crowds immersing themselves in the 
sacred spot. J The worship of Juggernauth has 



* On Animal Decomposition, etc. By H. Hartshorne, 
M.D. Philadelphia Med. Examiner, August, 1855. 
f Hygiene of the Army in India, p. 63. 
% Stocqueler, Handbook of India, p. 366. 



CAUSATION. ' 49 

produced a greater mortality still. The average 
of pilgrims annually visiting the temple of this 
deity was, a few years since, 120,000. Of these, 
thousands die from famine, fatigue, and exposure, 
and are left on the road to rot. 

The annual wide overflow of the Ganges, and 
its withdrawal in the dry season, must increase 
the amount of animal decomposition. The Nile 
also inundates, every year, the land of Egypt. 
How is it, then, that cholera has but half a dozen 
times invaded the latter country, while always at 
home in India ? I conceive the difference to have 
a twofold, and yet very simple explanation. The 
climate of Egypt is proverbially dry, from the 
vicinity of the great deserts. Decomposition there 
meets with its minimum of rapidity. The skin 
of an Ibis, shot for me in Upper Egypt, simply 
cleaned without anything antiseptic, and hung up 
on the deck of a boat in the sunshine, kept for 
two weeks without any odor or other sign of 
putrefaction. 

Further, the inhabitants of Egypt neither bury 
nor drown themselves from superstition in the 
river Nile. If their habits were not, in some lo- 
calities, especially when crowded away from their 
homes, uncleanly, there ought, and would, I be- 
lieve, never be any cholera in Egypt. 

The Hindoos, however, must be inconceivably 
filthy in many ways. S. Rogers, F.R.S., a British 



50 



ON CHOLERA. 



army surgeon, gives the following example, in a 
Report on Cholera in Madras : 

" The Coom river nearly encircles the village of 
Chintandrepett. This river was made a privy of 
' by hundreds of natives, daily ; when the water be- 
came low, the smell was most offensive. In the 
hot weather, an attack of cholera was the certain 
result, the only victims being those residing with- 
in a short distance of its banks. " 

In Europe and the United States, as well as in 
India, influences belonging to closely aggregated 
communities have always been observed to dis- 
play a power to propagate cholera. It comes 
most often, stays longest, and is most destructive, 
in the densest and filthiest cities, and in the worst 
quarters of those cities. In even the densely pop - 
ulated country of Holland, Suermann found the 
mortality to be 1*54 in 1000 in rural districts; in 
the towns, 8*93 in 1000. Moscow, Paris, Mar- 
seilles, Liverpool, Manchester, Edinburgh, New 
York, and Quebec have had great mortality from 
it. That of Moscow, in 1832-33, was 1 death 
from cholera in 32 of the whole population. 

Dr. Baly says, in his " Report" upon cholera in 
England, that "in the evidence received, lowness 
of site is not very prominently set forth among 
the unfavorable sanitary conditions; being, in 
fact, specifically mentioned only five times ; while, 
out of 68 places where cholera raged, bad ventila- 






CAUSATION. 51 

tion and overcrowding of houses are mentioned 
fifty-four times, defective drainage twenty-eight 
times, cess-pools, open sewers, etc., sixteen times." 

Three prisons at Wakefield, all on one plot of 
ground, seventeen acres in extent, differed* in chol- 
era mortality precisely in proportion to their re- 
spective sanitary conditions. Stewart Clark men- 
tions corresponding facts in India. This author 
also mentions a case narrated by Dr. Thompson, 
in which cholera affected one side only of a ship, 
which was foul ; the disorder ceasing when purifi- 
cation was effected. 

Very important testimony exists as to the influ- 
ence of the drinking water of localities. Having 
shown that Dr. Snow's theory is insufficient, we 
find such testimony available still in regard to the 
propagating and extending power of animal con- 
tamination. Thus, Bethlehem Hospital, supplied 
by an artesian well, had, in 1849, among 400 in- 
mates, no case of cholera. It was the only large 
lunatic hospital in London which escaped ; as it 
was the only one supplied with spring water. In 
the districts of London supplied from the Thames 
above the entrance of the sewers, the mortality 
ranged from 8 to 33 in 10,000 of the inhabitants; 
in those supplied from below the entrance of the 
sewers, from 28 to 205 in the same number. 

* Baly, op. cit, p. 20. 



52 



ON CHOLERA. 






In this country, Dr. James Wynne's report* 
affords, upon almost every page, matter of exactly 
the same purport as the above. In St.. Louis, 
Louisville, Buffalo, New York, Philadelphia, Bos- 
ton, etc., similar facts were recorded. It is unne- 
cessary to extract them, they are now so familiar 
and so commonly accepted. 

All of Pettenkofer's and Thiersch's observations, 
in regard to subsoil accumulation and transit, and 
fgecal fermentation after discharge, range them- 
selves now naturally under the one general fact 
which they exemplify, viz., that animal decompo- 
sition is the one great promotive cause of cholera ; 
to which heat and moisture, etc. are merely ad- 
juncts. 

But, that which suggested first to me this opin- 
ion was, the singular history of the outbreak at 
Columbia, Lancaster County, Penn., in Septem- 
ber, 1854. Cholera had never visited that town 
before. It is not large or populous, in a rural 
site, on the Susquehanna, not densely built enough 
to exclude malarial fevers. Why should it have 
cholera at all ? 

Visiting the town, with other physicians of our 
city, during the epidemic, I learned that an ex- 
ceeding drought had reduced the channel of the 
river to an unusually low ebb, and that, in its bed, 



* Presented to Parliament, and published in 1852. 



CAUSATION. 53 

a short space above the town, a number of car- 
casses of sheep and other animals, thrown from 
the railroad trains, etc., were putrefying rankly in 
the sun. A reservoir which supplied many of the 
people with drinking water was filled from the 
river not far from that spot, and the wind blew 
from it directly over the town. The first subsi- 
dence in the disease, we were afterward told, at- 
tended a decided change in the wind. 

At Pittsburg, shortly after the above events, a 
similar epidemic occurred. A gentleman on a visit 
to that locality not many days before the disease 
broke out, informed me that the same condition of 
the river existed there, with a like abundance of 
accumulated putrefying animal matter, exposed 
to the sun. 

In Rhode Island, in the autumn of the same 
year, I was informed that the local existence of 
cholera in a few spots, otherwise very healthy, 
might be traced, in coincidence at least, with a 
practice not uncommon along the shore of the sea 
or bays, of dragging up fish in quantities by nets, 
and spreading them out to rot for manure. 

Enough, then, of these facts and of their argu- 
ment. There remains the great practical ques- 
tion, which they ought to help us to solve — what 
are the best measures ,for the local exclusion or 
prevention of cholera ? 



54 



ON CHOLERA. 



PBEVENTION. 

Quarantine is now urged by some, and appears 
to be even contemplated by the Government as a 
part of its duty. Is it available ? Will it do any 
good ? I say, no. Theoretically, if the views ad- 
vocated in the preceding pages are correct, it falls 
to the ground of course. But we have more than 
that to say against it. It never has succeeded; 
and never can. Let us look at the facts. 

I take the following from Dr. Brigham's work 
on cholera, published in 1832 :* 

" In Russia, immense lines of troops were formed 
for arresting its progress ; St. Petersburg was en- 
tirely surrounded by cordons sanitaires; but all 
these regulations, enforced by a powerful despotic 
government, were unable to prevent the approach 
and the spread of the cholera throughout the Rus- 
sian Empire. The efforts of Austria were equally 
unavailing ; for in a short time the disease passed 
her triple cordons and invaded the country from 
Poland. Prussia employed sixty thousand of her 
best troops to enforce her rigorous restrictions, and 
travellers bear testimony to their severity. And 
what (says the American Journal of Medical Sci- 
ences, May, 1832) have been , the results ? An im- 
mense expenditure of money, the suspension of 
commerce, a stop put to industry, multitudes de- 



* P. 302. 



PREVENTION. 55 

prived of the means of acquiring subsistence, and 
whole families plunged into misery and rendered 
favorable subjects for the disease ; but no stop to its 
extension ; on the contrary, its progress was ren- 
dered more fatal. As an instance of this, Breslau 
may serve as an illustration and a warning to 
other cities. That city contained 90,000 inhab- 
itants, active, commercial, and industrious,- many 
of them manufacturers and artisans. A quaran- 
tine of twenty days, with difficulties almost insur- 
mountable which it entailed, was established at 
the borders of the province, and maintained with 
a rigor which might serve as a model to other na- 
tions. But, in the midst of this apparent security, 
a woman living in a damp part of the town was 
attacked by the cholera, and in a few days the 
disease spread. The most minute researches on 
the part of the public authorities could not dis- 
cover any communication between this woman 
and any stranger or goods suspected of being in- 
fected. But when the disease spread, the authori- 
ties saw too late the deep injury which their sani- 
tary measures had inflicted ; a multitude of fami- 
lies, and thousands of individuals, were plunged 
into extreme misery, for the sudden cessation of 
commerce, and consequent suspension of labor, had 
deprived them of the means of subsistence. 

" Taught by sad and lamentable experience, 
Russia, Austria, and Prussia withdrew their cor- 
dons, and acknowledged not only their inutility, 



56 ON CHOLERA. 

but that they are productive of immense evils. 
Indeed, all the nations of Europe are (1832) aban- 
doning severe quarantine regulations." 

Dr. Alison, of Edinburgh, wrote thus in 1854 :* 

" It is a fact that cholera has made its way, not 
uniformly, but very generally, in spite of cordons 
and quarantine regulations." 

Dr. Gavin Milroy, one of the ablest and most 
industrious sanitarians of our time, published, 
about the same year, an essay with this title: 
11 The Cholera not to be Arrested by Quarantine." 
A writer in the Brit, and For. Medico- Chirurg. 
Review (July, 1861) cites from that and many 
other authentic sources facts of great interest bear- 
ing on the subject. This is his account of the state 
of quarantine in different countries : 

"What is most remarkable in the quarantine 
regulations of different countries at present, is the 
fact of their want of accordance ; hardly any two 
being alike. Another noticeable point is, that, the 
more liberal the government of a country gene- 
rally, and the freer its institutions, the fewer and 
less stringent are the quarantine restrictions. In 
the Baltic States, in Sweden, Denmark, Prussia, 
Holland, the regulations formally enacted may be 
considered almost as a dead letter ; so in Belgium, 
where they are rather nominally than really in 
force. In the United States of America, each 

*Brit. and Foreign Medico-Chirurg. Review, Jan. 1854. 






PREVENTION. 57 

State of the Union has its own code ; all of them, 
according to a resolution of the Quarantine Con- 
vention held at Philadelphia in 1857, inefficient 
and often prejudicial to the interests of the com- 
munity. In Chili and Peru, and along the whole 
western coast of South America, the tendency is 
to disregard all quarantine regulations, as inter- 
fering with the freedom of commerce. In that 
anarchical country, Mexico, quarantine is under no 
legislation, the Board of Health having unlimited 
power, which it sometimes exercises most tyran- 
nically. In the South of Europe, in the old king- 
dom of the Two Sicilies, the codes are, or were, 
most elaborate and rigorous. In France and Sar- 
dinia, they have of late years undergone revisal ; 
and yet, though somewhat improved, they are still 
open to great objection ; fortunately, however, they 
are mildly enforced. In the Ottoman dominions — 
including Egypt, in which, little before 1840, there 
were no quarantine restrictions — a system has 
been established as elaborate as could well be con- 
trived, and as inefficient as can well be imagined, 
being totally in opposition to the feelings and 
habits of the people."* 

All are familiar with the entrance of cholera 
from Arabia into Egypt, and afterward Europe, 

* At Marseilles, in France, the people are said to have 
lately, under panic, asked for the restoration of the quar- 
antine. 



58 ON CHOLERA. 

in the spring and summer of 1865. All existing 
regulations clearly failed then. We cannot but be 
astonished that, at the late " Cholera Conven- 
tion," held at the instigation, and almost under 
the dictation, of the French Emperor, increased 
rigor of quarantine should have been (against the 
remonstrance of a number of delegates, it is true) 
insisted upon as the desideratum hereafter. What- 
ever validity such an enactment may have in 
political relations, let us hope that it will have 
none whatever in a scientific aspect ; as it contra- 
dicts facts, reason, and true expediency. 

The inefficiency of quarantine is a matter of 
demonstration. As the author just quoted re- 
marks,* " quarantine, even when rigidly enforced, 
has not kept out diseases of the contagious nature 
of which there is no question ; such as small-pox, 
and other exanthemata. In Malta, for instance, 
we are assured on good authority, that in the 
short space of seven years, 1829-1835, in spite of 
quarantine regulations for their exclusion, that 
island was twice invaded by small-pox, one epi- 
demic proving fatal to 1500 persons out of a popu- 
lation of 114,000 ; and also hj measles, scarlatina, 
and hooping-cough. Yet at Malta the quarantine 
system has been enforced very regularly, and under 
more favorable circumstances as to efficiency than 
anywhere else." 

* Review, p. 40. 






PREVENTION. 59 

Quarantine, if sound in theory even, could not 
avail, never has availed in practice. Its infraction 
for smuggling and other inducements, is every- 
where constant and notorious ; this cannot be pre- 
vented. Macaulay (History of England, vol. v. p. 
52) states that when a contraband trade was, in 
the time of William III., carried on between 
France and England on the southeastern coast, 
" it was a common saying among the inhabitants, 
that if a gallows were set up every quarter of a 
mile along the coast, the trade would still go on 
briskly." 

One might think the history of blockade-run- 
ning, during the late rebellion in this country, 
might afford ample illustration and confirmation of 
this. Vain, indeed, would be the attempt to close 
our coast against the introduction of cholera, were 
it as contagious as small-pox, or as plague was 
once imagined to be.* 

The evils of quarantine are great, almost incal- 
culable. Sir John Bowring, speaking in the House 
of Commons in 1841, gave it as his belief that the 
losses from quarantine in the Mediterranean alone 
were not less than two or three millions sterling 
a year. 

But what if, instead of preserving, quarantine 

* The Governor of Eupatoria is said to have wished the 
British and French troops to undergo quarantine, at the 
opening of the Crimean war! 






60 ON CHOLERA. 

actually involves, often, sacrifice of life? No 
doubt this has many times occurred. With yellow 
fever, the quarantine epidemic in New York har- 
bor, a few years ago, exemplified this. In various 
quarters reports of travellers show the miseries 
and dangers of the lazaretto, and of the confine- 
ment on the vessel detained. 

What more do we need to show this than the 
very recent instance of the steamer England, at 
Halifax? Forty passengers, one account says 
fifty (out of 1202), died on this vessel during the 
voyage. She was prohibited from entering port ; 
all were detained on board, and, by April 14th, 
130 more deaths occurred ! In all, 159 died while 
in quarantine. If the twelve hundred passengers 
had been landed and scattered, I, for one, doubt 
the occurrence of the disease in a dozen of their 
number ; especially as it was reported as altogether 
confined to the steerage. 

Were such measures sure to preserve from the 
epidemic the whole people of our continent, a 
hecatomb like this might find excuse. In face of 
facts, I regard it as a barbarity. Pelissier, in 
Algiers, was thought a monster, for suffocating a 
band of guerrillas in a cave ; but what is this case 
of the England more like, except in motive ? It 
is closing up hundreds of people for death; as 
though one might lock the doors, and bar the 
windows, against all escape of a thousand people 
from a burning church ; such as that of which we 



PREVENTION. 61 

read so harrowing an account, some time back, in 
South America. 

As I write, the papers have account of another 
steamer, the Virginia, with over 1000 passengers, 
attacked in the same latitude and longitude. A 
striking confirmation of the view I have advanced. 

But it will be said or asked, would you abolish 
all quarantine — abandon all inspection of ships 
whatever? No; I would not. But I would 
abandon altogether the whole theory of quaran- 
tine, as against cholera most particularly. 

Ships should be inspected on approaching ports, 
because they may have unsanitary conditions in- 
tensified in them, on a scale sufficiently large to be 
important. This is, or should be, a part of sani- 
tary police. Nor should it (and here is a great 
point of difference) include any restriction of per- 
sons; at the most, longer than enough for cleans- 
ing of the body and of the clothing, and purifica- 
tion of merchandise, by fresh air, and possibly by 
some disinfecting process in certain cases. 

I insist that Sanitary Police includes the 
sum total of available measures for the prevention 
of cholera in any place. 

On this ground, the measures required are obvi- 
ous, and familiar. The thorough and frequent 
cleansing of all streets, alleys, courts, wharves, 
and vessels, private and public buildings, and 
empty lots ; the abatement of all nuisances ; daily 



62 ON CHOLERA. 

removal of offal ; efficient sewerage ; and conser- 
vancy, i.e. the cleansing, ventilation, and disinfec- 
tion of cess-pools and water-closets. Among all 
signs of danger of the location of cholera, none is 
more significant than the privy odor. Let it be 
everywhere annihilated. Lime, charcoal, dry earth, 
chloride of lime, Labarraque's chloride of soda, 
liquid coal tar, chloride of zinc, and sulphate of 
iron are about the most available of disinfectants. 

The fresh white-washing of cellars is useful; 
thorough ventilation and drying of them and of 
all parts of habitations, still more so. Chloride of 
lime may be placed, in a saucer, in any suspected 
room or other locality in a house. The same, in 
the solid form, or solution of green vitriol, may be 
thrown daily into a foul privy ; and, during cholera 
time, especially in the case of patients with the 
disease, every water-closet and vessel used may 
and should be disinfected constantly, by a dilute 
solution of chloride of zinc, chloride of soda, per- 
manganate of potassa, or carbolic acid. The im- 
mediate removal of all discharges from the sick- 
room, their disinfection and transportation to the 
safest possible place of elimination, ought to be 
imperatively maintained. All foul clothing must 
be promptly washed, or, if very bad, disinfected or 
burned. 

These precautions have been proved to be capa- 
ble of essentially limiting and mitigating the preva- 
lence of epidemics. 



PERSONAL PREVENTION 63 



PEBSONAL PBEVENTION. 

One principle will suffice here : to keep the 
system at par ; neither above its level of excite- 
ment, nor below that of its due strength. 

For this, regularity of life is required, in work, 
diet, mental movements, and all indulgences. The 
popular errors most common are, one, to suppose 
that living on rice or rice-water, avoiding fruits or 
vegetables, etc. , will be preventive ; another, to • 
think constant alcoholic stimulation beneficial for 
that end. Both are certainly wrong. 

In 1832 and 1849, the late Dr. Joseph Harts- 
home, my father, then in very large practice, 
allowed in his family all its usual variety of food : 
boiled corn, peaches, watermelons, cantelopes, etc., 
everything but cucumbers; and no cholera re- 
sulted from the liberty. My own subsequent ex- 
perience justifies the practice. Of course care is 
always needed as to quality and quantity. 

Of all those most likely to die when attacked by 
this disease, the drunkard stands first, according 
to all records. Nor is he one whit less apt to be 
attacked than others. Temperance, in all things, 
is essential to safety during epidemics of every 
kind. 



64 ON CHOLERA. 



TEEATMENT. 

To discuss all the modes of management pro- 
posed for cholera, would make a volume larger 
than this is meant to be. I shall merely enumerate 
those which have attracted the most attention; 
and then give my view as to what is so well sus- 
tained as to be worthy of further trial and some 
confidence. 
• 1. Bleeding. — This was largely practiced in 
India, in 1818-1825, by Corbyn, Scot, Annesley, 
and others. Without entering upon any argu- 
ment about it, I will simply say, that (as Dr. 
Brigham's quotations show) as many positive 
facts have been asserted on behalf of the success 
of blood-letting as of any other remedy in cholera. 
My father bled in several cases in 1832, and had 
confidence in the treatment, as "the most effectu- 
ally antispasmodic." In 1849 I bled in one case 
(a boy of twelve years of age), in incipient col- 
lapse. The blood at first was thick and black as 
tar ; in a few minutes it flowed more freely, and 
the patient recovered. I confess that the only 
thing which makes it unlikely that I will ever try 
or advise the repetition of this practice is, the 
want of courage to stem the overwhelming tide of 
professional and popular opposition now existing 
against it. In this timidity I may be wrong ; if 



TREATMENT, 



65 



so, another generation may afford the demonstra- 
tion of what is right, in such a way that no one 
can gainsay it. 

2. Calomel. — This, too, was an old East Indian 
remedy. Suggested by the almost universal ab- 
sence of bile in the discharges, which was thought 
to indicate the need of stimulation of the torpid 
liver, it has been more largely given than any 
other medicine in cholera. 

Unhesitatingly, I hold the opinion that calomel 
is of no earthly use in cholera. The argument in 
its favor, from the absence of bile in the stools, is 
rebutted by the fact of its abundance in the gall- 
bladder ; while the clinical experience quoted for 
its success is accounted for by the addition to it, 
almost always, of opium, in the prescription. Nor 
is the amount of success with it, even then, great. 
Such is Dr. Gull's conclusion, based upon the ex- 
amination of a great mass of evidence, given in 
his report.* 

Dr. Ayre, a British practitioner of some note, 
gave prominence to a modification of the old calo- 
mel treatment (in which twenty grains were some- 
times given at once), by prescribing a grain of 
calomel every five minutes during the attack. 

3. Saline Treatment. — Dr. Stevens, of Jamaica, 
proposed this, upon the view that the main patho- 



* Report, etc. of Drs. Baly and Gull, already cited. 

3 



66 ON CHOLERA. 

logical .element in cholera was the loss of salts 
from the blood in the discharges. After the gen- 
eral failure of saline solutions (of common salt, car- 
bonate and phosphate of soda, etc.), given by the 
mouth, had been conceded, Dr. Mackintosh, of 
Edinburgh, and others, tried the method of injection 
into the veins (half an ounce of common salt, and 
four scruples of sesquicarbon ate of soda, dissolved 
in ten pints of water, at 105° to 120° Fahrenheit). 
Under this plan, resorted to during collapse, of 
156 patients in Dr. Mackintosh's hands, only 
twenty-five recovered. Remarkably improvement, 
almost like a resurrection, appeared in several, who 
afterward fell again into collapse, and died. The 
suggestion has been recently made, that it may 
have been the temperature of the injected liquid 
which produced the benefit, so promising and yet 
transient. 

4. Eliminative Treatment. — Dr. George John- 
son, of London, has urged this with especial vigor. 
The castor-oil medication of cholera owes its trial 
to him. Some recent lectures of his on the pa- 
thology and treatment of the disorder give a full 
and very intelligent exposition of his views. A 
prominent idea with him is, that the general col- 
lapse is due especially to anaemia of the lungs, 
owing to spasmodic contraction of the pulmonary 
artery and its branches. I regard this as only a 
part of the universal arterial (and other) involun- 



TREATMENT. 



61 



tary muscular spasm, belonging to what I have 
called the ganglionic tetanus of the collapse. But 
the essential feature of Dr. Johnson's pathology 
is the opinion that, the disease being toxemic, a 
morbid poison exists which must be eliminated 
from the blood ; and that the discharges are the 
media of this elimination. Therefore, the vomit- 
ing and diarrhoea are salutary or relieving ; and 
ought to be rather encouraged than checked. He 
goes even so far as to repudiate the commonly 
accepted belief, that " premonitory diarrhoea" or 
" cholerine " ought to be checked ; considering it a 
fallacy to assert that those who are relieved of 
such symptoms by mild treatment were really, or 
would have been, cases of cholera at all. 

I am entirely unable, from observation or reflec- 
tion, to assent to these views. They have very 
few advocates or supporters, besides the distin- 
guished physician whose name and ability com- 
mand for them at present careful consideration. 
It is true that patients have died of cholera with- 
out vomiting or purging. I saw in 1849 a woman 
in collapse (from which she recovered) for several 
hours without either; and many such cases are 
on record ; though, in some, after death, the in- 
testines have been found to be distended with 
the rice-water liquid. But the checking of the 
discharges is almost always the sign of the im- 
provement and recovery of the patient. And we 



68 



ON CHOLERA. 



cannot, on Dr. Johnson's dictum, set aside or 
quash all the accumulated evidence, in Europe 
and in this country,* which shows that it is de- 
sirable and important to check all watery diar- 
rhoeas in cholera time — such fluxes having been 
proved to be often premonitory of cholera attacks. 

5. Ice to the Spine. — Dr. John Chapman's ice- 
bags threaten to become the "pathy " or therapy 
of the day, with those who are zealous and ven- 
turesome in experimental practice. Upon reasons 
of a physiological nature, not appropriate for dis- 
cussion here, I disbelieve altogether in the theory 
of his therapeutics. In his pamphlet upon " Diar- 
rhoea and Cholera," lately published, he gives but 
one case of the latter disease, and does not say 
whether the patient recovered or died. 

As ice is so useful when internally given in cho- 
lera, it may be safe and beneficial when applied to 
the spine. Not having seen it tried, I am not 
prepared to deny the possibility. It is one of the 
experiments to consider, in so desperate a disease. 
But, if it should hereafter prove useful, I should 
explain that result quite otherwise than Dr. Chap- 
man has done, in part at least. 

6. Sulphuric Acid. — Dr. Cox, of England, after- 



* See Lectures on Cholera, by Prof. A. Clark, of New 
York ; Report to the Royal College of Physicians, 1854 ; 
also, Madin, Briquet and Mignot, etc. 



TREATMENT. 



69 



ward Mr. Buxton and Dr. Fuller, and very re- 
cently Dr. Jules Worms, of Paris, have especially 
recommended dilute sulphuric acid in all stages of 
cholera. Many others especially report well of its 
action in the premonitory diarrhoea. Such an 
action would comport perfectly with the view I 
have taken of the organic nature of the poison of 
cholera ; sulphuric acid being so potent a destroyer 
of everything organic, except such mirabilia as 
the Acarus Crossii. 

Dr. Worms' treatment (based on the results in 
238 cases of cholera, and 150 of cholerine, in 
1865) is as follows: For prodromic diarrhoea, he 
makes a "mineral lemonade," of about half a 
drachm of concentrated sulphuric acid to a pint 
or more of sweetened decoction of salep (arrow- 
root would do as well). The patient is to take of 
this every hour a wineglassful, till relieved. 

For confirmed cholera, the patient being kept in 
complete repose, there is administered every half 
hour a glass of a similar lemonade, of the strength 
(about) of a drachm to the pint ; ice and wine also 
being allowed ad libitum. 

7. Opium in large doses. — This practice had 
once many advocates ; now they are few. Prof. 
Austin Flint, of New York, is one of them ; at 
least morphia is advised by him, in full dose, 
repeated if required. A great deal of evidence of 
the insufficiency of such a plan has been published ; 



70 ON CHOLERA. 

although it is not worse than several other me- 
thods. Letting alone would probably be better. 
The secondary fever is apt to be more severe and 
more often fatal after treatment of the attack by 
large doses either of opiates or stimulants. Large 
quantities of brandy (I add, by the way) have 
been often used, with no good results. 

Statistics are given, as follows, of the results of 
some of the most common modes of practice in 
cholera, by practitioners in Great Britain, as re- 
ported to the " Treatment Committee of the Medi- 
cal Council of the Board of Health," 1854-55. 

Taking all grades of the disease, the deaths 
were — 

Per Cent. 

With Eliminants 71-7 

Stimulants 54 

Calomel and Opium . . . .36-2 
Chalk and Opium . . . . 20-3 

Of collapsed cases, the mortality was — 

Per Cent. 
With Calomel and Opium . . . .59-2 
Larger doses of Calomel . . 60-9 

Salines 62-9 

Chalk and Opium . . . . 63-2 
Calomel, small doses . . .73-9 

Castor Oil 77-6 

Sulphuric Acid . . . .78-9 

Much is uncertain, obviously, in such statistics, 
without further account of dosage, circumstances, 



TREATMENT. fl 

etc. But this seems to follow ; that neither treat- 
ment has much to boast of success. 

8. Treatment by antispasmodics and mild 
stimulants, in small doses at short intervals ; 
with ice, and external frictions, etc. — In 1849, 
my first two cases of cholera were fatal; although 
assiduously watched, each for a day and a 
night. The third, I saw with the late Dr. Wm. 
E. Horner, Professor of Anatomy in the Univer- 
sity of Pennsylvania. I left the treatment to him. 
He sat down by the bedside of the patient — a 
man, blue, cold, and with a scarcely perceptible 
pulse, copiously vomited and purged, with rice- 
water. Having ordered ice,* Dr. Horner took 
from his pocket a vial containing a mixture of 
chloroform, oil of camphor, and laudanum ; which 
he gave in sweetened ice-water, in small doses, 
every Jive minutes by the watch. Each dose was 
followed by a piece of ice. 

Soon the vomiting diminished, afterward the 
diarrhoea, and in an hour and a half the veins on 
the back of the hand began to fill up, and the 
blood to return in them more rapidly after pres- 
sure. Diminishing the frequency of the doses, we 
left him, an hour later, evidently convalescent. 
When I saw him after several hours again, he was 

* Ice was used, and lauded, in cholera, by the celebrated 
Broussais, in 1882, 



?2 ON CHOLERA. 

sitting up in bed, at ease, and so changed, that I 
doubted at first his identity. No secondary fever 
followed ; he was cured. 

Naturally, I repeated this treatment in all my 
subsequent cases, some of which were of extreme 
severity; and with gratifying success. The 
memorandum-book of the number of these cases 
has, to my present regret, been mislaid. After 
the treatment of Prof. Horner had been adopted, 
however, I saw no death, except in the instance 
of a drunkard, two or three hours in collapse be- 
fore any medical treatment began. 

Should I be attacked with cholera, such is the 
treatment I desire. Conscientiously I believe, 
that nothing else will afford a better chance of 
recovery. I merely altered Prof. Horner's mix- 
ture to a tincture, for better presei^ation ; adding 
some minor adjuvants. This recipe will be given 
directly. Frictions and sinapisms may also be 
added. The great merits of this plan are its anti- 
spasmodic nature, and the administering of small 
doses at very short intervals. This is eminently 
demanded in cholera. Phthisis may be a com- 
plaint of years ; hooping-cough, of months ; ty- 
phus, of weeks ; pneumonia, of days ; but chol- 
era must be numbered by its hours, half hours, 
or even minutes. 

Having reached, then, this conclusion, I may 






TREATMENT. 73 

add, that a rationale for such a treatment is dis- 
cernible. I only follow many good authorities in 
the opinion that cholera is, symptomatically and 
pathologically, a poison-spasm, or tetanus of the 
ganglionic system. Taken early, that condition 
may be prevented, by mild opiates and stimulants, 
in the premonitory stage. Later, while any medi- 
cines will act, these will do the most. What is 
needed in confirmation of this explanation, more, 
than is given by the action of quinine in prevent- 
ing an anticipated chill, or, of the same, in full 
quininization, curing the paroxysmal disease (a 
toxaemic neurosis) of intermittent ? An antagon- 
istic influence against that which so perturbs in- 
nervation throughout the body ; such is the whole 
definition that we can give of the remedial power 
shown in either case. 

Let me be more specific in reference to treat- 
ment. Premonitory diarrhoea is very generally 
admitted to be present in a majority of cases of 
cholera.* In the East Indies, many writers, of 
different dates (Lawrie, 1832, Stewart Clark, 
1864, etc.), assert such a stage to be an exception 
instead of the rule. But, in India, they have a 
premonitory or incipient stage of another kind; 



* Barraut asserts fixed contraction of the pupil to be 
the first prodromic sign; M. Worms makes the same state- 
ment in regard to albuminuria. 



74 



ON CHOLERA. 



characterized by great languor or depression, with 
restlessness, and sometimes ringing in the ears, 
occurring mostly in the night. Stewart Clark 
states* that, in this stage, a mild opiate ("with a 
little calomel or blue pill "), with a cup of warm 
tea or a small dose of a diffusible stimulant, as a 
few grains of carbonate of ammonia, or a little 
weak warm brandy and water, will arrest the at- 
tack in a great portion of cases otherwise to be- 
come serious. 

Such symptoms, as well as diarrhoea, should be 
noticed here, during a cholera epidemic ; and I be- 
lieve the same treatment will meet both. Rest, 
warmth, and mild, composing, but gently stimulat- 
ing draughts ; paregoric, aromatic spirit of ammo- 
nia, tincture of ginger, lavender, etc., with a mus- 
tard-plaster over the abdomen, and a hot mustard 
foot-bath if coldness of the body increase, or vom- 
iting begin ; such are safe, and I believe will be 
efficient remedies. The above may be called the 
first or prodromic stage, f 

The next has been well called, by Prof. A. 
Clark, the rice-water stage. For that, the treat- 
ment I have described as given to me by Prof. 



* Hygiene of the Army in India, p. 12. 

f The recently published experience of Dr. Hamlin, in 
Constantinople, confirms the importance of the above 
early treatment. 



TREATMENT. 75 

Horner is particularly adapted. My recipe, based 
upon his, is as follows : 

R. — Chloroform, et 
Tinct. Opii et 
Sp. Camph. et 

Sp. Amnion. Aromat, aa f 3jss ; 
Creasot. gtt. iij ; 
01. Cinnamom. gtt. viij; 
Sp. Vin. Gall, fgij.— M. 

Dissolve a teaspoonful of this in a wineglassful 
of ice-water; and give of that two teaspoonfuls 
every five minutes; followed each time by a lump 
of ice.* 

Friction of the limbs with brandy and red pep- 
per will be, along with large mustard-plasters on 
the back and pit of the stomach, useful to promote 
reaction. 

The third stage is that of absolute collapse; 
blue, pulseless, shrunken, voiceless. Should a case 
go on, in spite of the above-mentioned treatment, 
into this state, what else can be done ? All now 

* I take from Dr. Aitken's Practice the followhig recipe, 
much used and approved in India and England : R. — 01. 
Anisi, 01. Cajeput., 01. Juniperi, aa gss; iEther, gss; 
Liq. Acid. Halleri {i. e. one part concentrated sulphuric 
acid to three parts of rectified spirit), £ss ; Tinct. Cinnam., 
gij. — M. Dose, 10 drops every \ of an hour, in a table- 
spoonful of water. 






76 



ON CHOLERA. 



seems to be desperate experimentation.* Let the 
ice-bags be tried, and judge them by the trial. I 
would also try belladonna internally, as an antag- 
onist of vascular spasm. Leclerc, of Tours, intro- 
duced it in 1854; Barraut, of Mauritius, used it 
(£ grain every half hour), and reported success. 
He also employed hypodermic injections of sul- 
phate of atropia. This should be tried again in 
bad cases. So might be, as was suggested by me 
in 1855, warm baths of infusion of stramonium 
(Jamestown weed) leaves; on the same indica- 
tion. Also, the injection of hot liquids into the 
rectum ; the warm bath (hot baths cause distress 
in the collapse), with carbonate of ammonia 
added, as used sometimes in malignant scarlet 
fever (West) in children ; or, the warm mustard 
bath. Hot airf bathing, if practicable, in the 
manner so praised of late by Erasmus Wilson and 
others, would be worth trying ; and so would even 
the inhalation of nitrous oxide. Let us confess 
honestly, for it is wise to do so, our art is here 
very weak ; fifty per cent, or more of collapsed 
cases die; shall we not endeavor to discover new 



* Duchaussoy and Vernois assert the non-absorption of 
medicines given by the stomach during the collapse ; but 
Magendie proved that a very slow absorption does occur. 

f Dr. George Johnson states that he has seen the hot- 
air bath used without success. 



TREATMENT. 71 

resources ? All honor to those who, at the risk 
of their own lives, contend yet, with so forlorn a 
hope, and so little glory to be won. There is 
room yet for, and possibility of obtaining, a final 
triumph. 

Two words remain still to be said, with short 
comment: house to house visitation, and houses 
of refuge. These are measures of great conse- 
quence, shown to be of value during cholera epi- 
demics. The latter, especially, is of notable im- 
portance ; that is, the establishment of houses of 
refuge in salubrious places, into which persons 
from tainted districts most liable to the disease 
may be received, on the occurrence there of the 

first cases. 

■ 

That there are such tainted districts, has been 
amply proven. Thus, Dr. Laycock has shown 
that in York, England, the first death from chol- 
era occurred in the spot where plague had been 
traditionally the worst, in a badly-drained district. 
In Edinburgh, the first case in 1848 occurred in 
the same house as did the first in 1832. In Hol- 
land, at the town of Groningen, in 1832 and 1848 
but two houses in the better part of the town 
were attacked ; the same houses exactly in both 
epidemics. 

Dr. Alison reports that in the first three months 
of the epidemic at Edinburgh, in 1832, 353 per- 
sons were taken in at Houses of Refuge, from TO 



IS 



ON CHOLERA. 



tainted districts, houses, and rooms in which de- 
cided cases or deaths had occurred. Of these, 
only 15 took the disease, and 7 died after removal. 
Of the 346 thus surviving brief exposure, it is very 
probable that more than half would have died had 
they remained in the midst of the infection. At 
Glasgow, in 1849, 401 persons were taken into 
Houses of Refuge from tainted districts; only 19 
of these took the disease and but 5 died. At Ox- 
ford, England, the same year, of TO persons so 
taken in, none died. The London Board of Health, 
in its " General Report," gives the fact that of 1691 
of whom the Board had accounts as taken into 
Houses of Refuge, but 33 were attacked, with only 
10 deaths. These numbers would have been 
larger, but for the very common unwillingness of 
poor and ignorant people to leave their homes, 
chiefly from want of confidence in the greater 
safety of so doing. Could this be overcome, I 
have no doubt that an immense saving of life 
might be produced by Houses of Refuge, allowing 
also the places which are proved " foci of infection" 
to be thoroughly purified at once. 

House to house visitation, by sanitary inspec- 
tors to abate nuisances, small and great, and by 
medical men to treat premonitory symptoms, 
might also have great preventive value. The 
establishment of cholera hospitals may be made 
necessary when the number of cases is great, espe- 



TREATMENT. 79 

daily as the greatest proportion always happens 
among the poor, who are ill provided for attend- 
ance at their homes. 

There should be no panic about cholera ; espe- 
cially in Philadelphia. Let our authorities do 
their full duty, in sanitary measures of local im- 
provement and renovation ; let them give to our 
city its pristine cleanliness, and cholera may reach 
and sweep across the continent without a case oc- 
curring here. Baltimore has had such an immu- 
nity more than once. And, in our worst visitation, 
the mortality has not been very great. Pear, 
moreover, aggravates the danger. 

While, if it come, those who can leave as well as 
not, will, undoubtedly, be most safe in the open 
country, for those whose duties keep them in the 
city, courage and equanimity are not only becom- 
ing but expedient. 

There is but slight exaggeration in the prover- 
bial assertion, that " Pestilence kills thousands, 
but Fear tens of thousands." Above all, let us 
hope that no mistaken terror of contagion will 
ever lead to the extreme barbarity of desertion of 
the sick or neglect of the dead. 

Cholera is not, after all, a hard death to die. 
To me, it appears one of the easiest modes of exit 
from the world. 



K 



CHOLEEA: 




FACTS AND CONCLUSIONS 



AS TO ITS 



NATURE, PREVENTION, AND TREATMENT. 



BY 



HENRY HARTSHORNE, A.M., M.D., 

MEMBER OF, THE AMERICAN PHILOSOPHICAL SOCIETY; FELLOW OF THE COLLEGE 

OF PHYSICIANS OF PHILADELPHIA; PROFESSOR OF HYGIENE IN 

THE AUXILIARY FACULTY OF MEDICINE IN THE 

UNIVERSITY OF PENNSYLVANIA, ETC. 

I 




PHILADELPHIA: 

J. B. LIPPINCOTT & CO. 

1866. 



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